Fluid Resuscitation in

Sepsis

A Literature Review

"On the floor lay a girl of slender make and juvenile height,

but with the face of a superannuated hag... The colour of

her countenance was that of lead - a silver blue, ghastly tint;

her eyes were sunk deep into sockets, as though they had

been driven an inch behind their natural position; her

mouth was squared; her features flattened; her eyelids black;

her fingers shrunk, bent, and inky in their hue…

The Pioneers

Dr Latta’s Saline Solution

Two to three drachms of muriate of soda (NaCl), two scruples of the

bicarbonate of soda in six pints of water and injected it at temperature

112 Fah

( approximately 58mmol/l Na+, 49mmol/l Cl-, 9mmol/l HCO3-)

Ten of the first fifteen patients died

180 years on…..

Current controversies in fluid therapy in

septic patients

When to give fluid

How much fluid to give

Which fluid to use

Definitions

• SIRS: widespread inflammatory response that may or may not

be associated with infection: 2 or more of

– Temperature, tachycardia, tachypnoea and WCC

• Sepsis: SIRS in the presence of or as a result of suspected or

proven infection

• Septic shock: Sepsis with cardiovascular dysfunction despite

the administration of >40ml/kg isotonic fluid in one hour

Epidemiology

• Angus et al. Epidemiology of severe sepsis in the United States:

Analysis of incidence, outcome and associated costs of care. Critical

Care Med 2001; 29: 1303-1310

– Estimated 750,000 cases of severe sepsis annually in US

– Mortality of 28.6%

– $22,100 per case

• Starship Hospital

– 2010-2012

– 90 cases of sepsis/septic shock

Pathophysiology

The Evidence

When to give fluid

How much fluid should we give

Early Paediatric Practices

• Early 1980’s

– Slow cautious fluid bolus: 10-20ml/kg over 20-30 minutes

• Era of limited paediatric ventilators/PICU

• Awareness of SIADH in patients with sepsis and meningitis

• 1988

– The AHA’s Textbook of PALS

– Rapid 20ml/kg fluid boluses to a total of 60ml/kg or more in the

first hour of resuscitation

Carcillo et al. Role of Early Fluid Resuscitation in

Pediatric Septic Shock. JAMA 1991; 266 (9): 1242-1245.

• Children’s Hospital National Medical Centre

– 1982-1989

• All patients with septic shock with a PAC at 6

hours

– Group 1: up to 20ml/kg

– Group 2: 20-40ml/kg and

– Group 3: >40ml/kg in first hour

• End points: survival, ARDS, hypovolaemia at 6

hours

• 34 patients

– Median age 13.5 months

– Pre-existing chronic disease in 31%

– 82% required ventilation

– 100% required inotropic support

• Fluid resuscitation

– Crystalloids (0.9% or lactated Ringer’s)

– Colloids: 5% albumin or blood products

(RBC, FFP, cryoprecipitate)

Carcillo et al. Role of Early Fluid Resuscitation in

Pediatric Septic Shock. JAMA 1991; 266 (9): 1242-1245.

• Criticisms

– Treatment groups assigned non-randomly

– Treatment based on clinical criteria

– Criteria determined by different individuals

• But….findings suggested current PALS guidelines

may improve survival in children with septic shock

Rivers et al. Early Goal-Directed Therapy in the Treatment of

Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-77

• To evaluate the efficacy of EGDT before

admission to ICU

– Single center: Detroit Hospital

– Emergency Department

• 263 patients: severe sepsis or septic shock

– Randomly assigned

– 6 hours of standard versus EGT

– End points: MOF, mortality,

Rivers et al. Early Goal-Directed Therapy in the Treatment of

Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-77

• Results

– 263 patients

• 8.7% excluded or did not consent

• Similar baseline characteristics including adequacy and duration of antibiotic

therapy

– Standard patients in ED 6.3 hours v 8 hours (p<0.001)

• No difference in HR or CVP

• MAP’s significantly lower

Rivers et al. Early Goal-Directed Therapy in the Treatment of

Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-77

• Criticisms

– Single center

– Single physician

– Treatment group mortality similar across centers

Carcillo et al. Clinical practice parameters for haemodynamic

support of paediatric and neonatal patients in septic shock. Critical Care Med 2002; 30:1365-1378.

St. Mary’s Hospital, London

• Specialist Tertiary Referral Centre, 2002

– High rates of meningococcal disease

– Consultant led retrieval service

– Telephone advice throughout the south of England

– Centralization of meningococcal disease care

• Early aggressive fluid resuscitation

– 4% Albumin

deOliveira et al. ACCM/PALS haemodynamic support guidelines

for paediatric septic shock: an outcomes comparison with and

without monitoring central venous saturation. Intensive Care

Medicine 2008; 34: 1065-1075.

• 102 children with severe sepsis or fluid refractory septic shock

– Randomly assigned to ACCM/PALS with or without ScvO2 goal-directed resuscitation for 72 hours

• Control group

– ACCM/PALS therapies without continuous ScvO2

– Fluid resuscitation (crystalloid or colloid), RBC or CVS drugs

– Maintain normal perfusion pressure for age, UO >1ml/kg/hour, CRT of 2 seconds and normal pulses

• Intervention group

– Endpoint of ScvO2 >70% using continuous monitoring

– If <70% then more fluid, RBC (if Hb<10g/l) or inotropes were given

• Other supportive therapies: CMV, nutrition, antibiotics and RRT decided by medical team

deOliveira et al. ACCM/PALS haemodynamic support guidelines for paediatric

septic shock: an outcomes comparison with and without monitoring central

venous saturation. Intensive Care Medicine 2008; 34: 1065-1075.

• Intervention Group

– 28 day mortality (11.8% v 39.2%)

– More crystalloid (28 v 5mls/kg)

– RBC transfusion (45.1% v 15.7%)

– More inotropic support (29.4% v 7.8%)

– Fewer new organ dysfunctions

• Support of the current ACCM/PALS guidelines

– Goal-directed therapy using the endpoint of ScvO2 >70% provided a significant

impact on the outcome of children

Guideline Update

• Brierly et al. Clinical practice parameters for haemodynamic

support of pediatric and neonatal septic shock: 2007 update

from the American College of Critical Care Medicine CCM

2009;37:666-88

• Surviving Sepsis Campaign guidelines for the management of

severe sepsis and septic shock. Critical Care Med 2008.

36(1):296-327

Improved outcomes in paediatric septic shock

• Han et al. Early reversal of pediatric-neonatal septic shock by

community physicians is associated with improved outcome.

Pediatrics 2003; 112:793-9

• Inwald et al. Emergency management of children with severe

sepsis in the UK: the results of the Paediatric Intensive Care

Society sepsis audit. Arch Disease in Childhood 2009;94:348-53

Background

• Early aggressive fluid resuscitation in patients with shock

• sub-Saharan Africa

– Malaria, sepsis and other infectious disease

– High early mortality

– Fluid resuscitation not practiced unless severe anaemia

• WHO recommends fluid resuscitation in advanced shock only

– CRT > 3 seconds

– Weak and fast pulse

– Cold extremities

Aims

• FEAST trial designed to investigate the practice of:

– Early resuscitation with a saline bolus as compared with

no bolus (control)

– With an albumin bolus as compared with a saline bolus

Study Design

• 2 stratum, multi-center, open, randomised controlled study

– January 2009-2011

– Age between 60 days and 12 years

– 6 clinical centers: 1 Kenya; 1 Tanzania; 4 Uganda

• Stratum A

– Children without severe hypotension

• Stratum B

– Children with severe hypotension

• SBP <50mmHg if <12 months; <60mmHg if 1-5 years; < 70mmHg >5 years

Study Design

Stratum A Stratum B

Randomly assigned 1:1:1

Rapid volume expansion over 1 hour

20mls/kg (40ml/kg June 2010)

1. 0.9% NaCl (saline-bolus group)

2. 5% HAS (albumin-bolus group)

3. none (control group)

Additional 20ml/kg bolus at 1 hour if

impaired perfusion (not in control group)

Severe hypotension: 40ml/kg of study fluid

(saline in control group)

Randomly assigned 1:1

Rapid volume expansion over 1 hour

40ml/kg (60ml/kg June 2010)

1. 0.9% or (saline-bolus)

2. 5% HAS (albumin-bolus)

Additional 20ml/kg bolus at 1 hour if

impaired perfusion

Severe hypotension: 40ml/kg of study fluid

Study Population

Inclusions Exclusions

Age 60 days to 12 years

Severe febrile illness complicated by

Impaired consciousness

Respiratory distress

Impaired perfusion

1. CRT >3 seconds

2. Lower limb temperature gradient

3. Weak radial-pulse volume

4. Severe tachycardia

Severe malnutrition

Gastroenteritis

Non-infectious causes of shock

1. Trauma

2. Surgery

3. Burns

Conditions for which volume expansion is

contraindicated

End Points

• Primary End Point

– Mortality at 48 hours

• Secondary End Points

– Mortality at 4 weeks

– Neurologic sequelae at 4 & 24 weeks

– Episodes of hypotensive shock within 48 hours after randomisation

– Adverse events potentially related to fluid resuscitation

• Pulmonary oedema

• Increased ICP

• Severe allergic reaction

Study Procedures

• Treated on general paediatric ward

– Assisted ventilation bag-mask only

– Provided with monitors for saturations and blood pressure

– Training in triage & emergency paediatric life support

• Supportive management

– IV maintenance fluids (2.5 – 4ml/kg/hour)

– Antibiotics, anti-malarials, anti-pyretics, anticonvulsant drugs

– Treated for hypoglycaemia (<2.5mmol/L)

– RBC transfusion at 20ml/kg over 4 hours if Hb <5g/dl

Study Procedures

• Clinical case-report form completed at 1,4, 8, 24 and 48

hours

– Hypovolaemia, neurologic and cardiorespiratory status

– Adverse events were reported

• Neurological assessment at 4 weeks

– Reviewed by independent clinician

– Reassessed at 24 weeks if neurological sequelae present

Administered Fluids

• Adherence to protocol

– 99.5% in albumin group

– 99.4% in saline group

– 99.9% in control group

• Median volume of all fluids (including blood):

– Albumin Bolus Group: First hour: 20ml/kg; Second hour: 4.5ml/kg

– Saline Bolus Group: First hour: 20ml/kg; Second hour: 5ml/kg

– Control Group: First hour: 1.2ml/kg; Second hour: 2.9ml/kg

Fluid Administered

• Over course of 8 hours

– Median cumulative volume of fluid

• Albumin-bolus group: 40ml/kg (30-50)

• Saline-bolus group: 40ml/kg (30.4-50)

• Control: 10.1 ml/kg (10-25.9)

• RBC transfusion in 1408 children

– 45% in albumin; 47% in saline; 43% in control

– Initiated earlier in control group but proportions and volumes similar

across all groups

Good Points

• Large numbers of children enrolled

• Multinational nature of sample

• Small numbers lost to follow up

• Blinding of treatment assignments

• High rate of adherence to assigned treatment

• Confirmed what we know about saline versus albumin

Limitations

• Setting

• Limited access to diagnostics

• Different pattern of disease e.g. cerebral malaria

• Exclusions: gastroenteritis, severe malnutrition or non-

infectious causes of shock

• Few children recruited to stratum B

• Definitions of ‘shock’

Restricted Fluid Strategy

• Adult Literature

– ARDS

– Colorectal Surgery

– Penetrating Trauma

What type of fluid?

Types of IV Fluids

Crystalloids Colloids

Isotonic

0.9% Saline

Plasma-Lyte

Hartman’s solution

Lactated Ringer’s Solution

Hypertonic

3% Saline

Natural

4% Albumin (iso-oncotic)

20% Albumn (hyper-oncotic)

Synthetic Colloids

Dextrans: 6% dextran 70; 10% dextran 40

Gelatins: Gelofusin, Haemaccel, gelofundiol

HES preparations: Tetrastarch, Pentastarch,

Voluven

Crystalloid versus Colloid

Crystalloids Colloids

Cheap

Readily available

Hyperchloraemia

Expensive

Anaphylaxis

Coagulopathy

Exposure to blood products

Pruritis

Albumin

• Human albumin

– Natural colloid, MW 69kDa

– Accounts for 80% plasma oncotic pressure

– Drug & hormone transport

– Anti-oxidant and anti-inflammatory properties

– Hypoalbuminaemic critically ill patients have a worse prognosis

• Albumin solutions

– Safe, natural, well tolerated

– Iso-oncotic (4% or 5%) or hyper-oncotic (20-25%)

Levin et al. Improved survival in children admitted to intensive

care with meningococcal disease. 2nd Annual Spring Meeting of the

RCPCH. University of York. 1998

The Colloid versus Crystalloid Debate

• Cochrane Injuries Group Albumin Reviewers

– Human albumin administration in critically ill patients: Systematic

review of randomised controlled trials. BMJ 1998; 317: 235-240

– 30 RCT including 1419 randomised patients

• Burns, hypoalbuminaemia or hypovolaemia

• 6% increased risk of death with albumin

Booy et al. Reduction in case fatality rate from meningococcal

disease associated with improved healthcare delivery. Arch Dis

Child 2001; 85:386-390.

• 331 children with MD admitted to PICU

– 1992-1997

– Case fatality rate 23% (1992/93) to 2% (1997)

• A significant improvement in outcome for children admitted with MD to a

PICU as a result of improvements in the use of their algorithm:

– 4% albumin boluses

– Initial management at referring hospitals

– Use of a mobile intensive care service

– Centralization of care in a specialist unit

Finfer et al. A Comparison of Albumin and Saline for Fluid

Resuscitation in the ICU NEJM 2004; 350:2247-56

The SAFE Study

• 2001-2003

– Multicenter, randomised, double-blind trial

– Primary outcome: death from any cause/28 days

• Eligible patients

– Anyone for whom fluid resuscitation required

– Exclusions: cardiac surgery, liver transplant, burns

– 4% albumin versus 0.9% saline

The SAFE Study

• 6997 patients

– Similar baseline characteristics

• Fluids Administered

– Albumin group: significantly less study fluid

– Saline: Albumin of 1: 1.4

• Haemodynamics

– No differences in MAP

– Albumin group: lower HR & higher CVP

Total Fluids Administered

Albumin Saline Ratio

2247ml 3096ml 1:1.4

The SAFE Study

• 28 day mortality

– 726 deaths (20.9%; albumin) v 729 deaths (21.1% saline)

• Single organ and multiple-organ failure similar

– No differences in ICU days, hospital days, days of

mechanical ventilation, days of RRT

The SAFE Study

• Sub–group analysis in severe sepsis

– Improved outcomes with albumin

• Saline group 35.3% died

• Albumin group 30.7% died

– RR of death 0.87 amongst those in the albumin group

• RR of death 1.05 without severe sepsis

Paediatric Albumin Trials

• Maitland et al. Randomized trial of volume

expansion with albumin or saline in children with

severe malaria: preliminary evidence of albumin

benefit. Clin Infect Dis 2005; 40(4):538-45

• Maitland et al. Mortality after fluid bolus in

African children. NEJM Jun 30;364(26):2483-95

Current Trials

• The PRECISE Trial

– Evolution of an Early Septic Shock Fluid Resuscitation Trial

– Canadian Critical Care Trials Group.

– 5% albumin versus 0.9% NaCl on 90 day mortality

• ALBIOS Trial

– The Volume Replacement with Albumin in Severe Sepsis

– 1350 Italian ICU patients

– 28- and 90-day mortality; organ dysfunction (secondary end-point)

– Albumin plus crystalloid versus crystalloid only

Surviving Sepsis Campaign guidelines for the management of

severe sepsis and septic shock. Critical Care Med 2008. 36(1):296-

327

• Dellinger et al. Surviving Sepsis Campaign: International

guidelines for management of severe sepsis and septic

shock: 2008. Intensive Care Med 2008; 34:17-60

• Recommends the use of either crystalloid or colloid for

the early resuscitation of patients with sepsis

Gelatins

• Synthetic colloid

– Hydrosylates of connective tissue of animal origin

– MW limited to 30-35 kDA

• Tendency to gel at higher molecular weights

• Much lower than albumin

• Limited oncotic effects; intravascular persistence 2-3

hours

Gelatins

• Upadhyay et al. Randomized evaluation of fluid

resuscitation with crystalloid (saline) and colloid (polymer

from degraded gelatin in saline) in pediatric septic shock.

Indian Pediatr 2005; 42(3):223-31

– 60 children with septic shock

– 20ml/kg boluses of saline or gelatin

– Equally effective as a resuscitation fluid

Gelatin

• Acute Kidney Injury

– Schabinski et al. Effects of a predominantly HES based and

a predominantly non HES based fluid therapy on renal

function in surgical ICU patients. Intensive Care Medicine

2009; 35:1539-1547

• 6% HES 130/0.4 versus gelatin

• Gelatin exposure independent RF for ARF (OR 1.99)

• Anaphylactoid reactions reported

Hydroxyethyl Starch

• Commonest colloid used in European ICU’s

– HES 58%; gelatin 35%; albumin 5%

– Synthesised by partial hydrolysis of maize or potato starch, amylopectin

• 4 Elements

– Concentration: 6% or 10%

– Molecular weight: 70-670kDa

– Degree of substitution: 0.4 (tetrastarch), 0.7 (hetastarch)

– C2/C6 ratio

• 3 Generations

HES & Bleeding

• Cardiac surgery RCT’s

– HES 120/0.7, 130/0.4, 200/0.5, 450/0.7 impaired TEG assessed clotting

compared with albumin

– Blood loss increased with HES 130/0.4 and 450/0.7 (greater blood

transfusion) compared with albumin

• General paediatric surgery patients

– HES 130/0.4 caused deterioration in TEG parameters in a RCT

compared with albumin

Acute Kidney Injury

• Schortgen et al. Effects of hydroxyethylstarch and gelatin on renal function

in severe sepsis: a multicentre randomised study. Lancet 2001;357:911-916

– 129 French patients with severe sepsis

– 6% HES 200/0.6 increased risk of RF by 2.57 compared with gelatin

• Brunkhorst et al. Intensive insulin therapy and pentastarch resuscitation in

severe sepsis. NEJM 2008:358:125-39

– 10% HES, 200kDa versus Ringer’s lactate

– Higher incidence of renal failure and RRT

Acute Kidney Injury

Consensus statement of the ESICM task force on colloid

volume therapy in critically ill patients. Intensive Care Medicine

2012; 38(3):368

• Recommend against using HES>200kDa and/or degree of

substitution of 0.4 in patients with severe sepsis or risk of

AKI

• Suggest not using 6% HES 130/0.4 in these populations

Anaphylactoid Reaction

• Wills et al. Comparison of three fluid solutions for

resuscitation in dengue shock syndrome. NEJM

2005:353:877-889.

– RCT of 383 children

– Severe allergic reactions more frequent after

– Dextran 70>HES 200/0.5>Ringer’s lactate

• Case reports described in patients exposed to gelatins, HES

and albumin

Pruritis

• Bork et al. Pruritus precipitated by hydroxyethyl starch: a

review. Br J Dematol. 2005; 152:3-12

– Systematic review of 18 clinical studies; 3239 patients

– All HES solutions of all molecular weights, substitutions and

C2/C6 ratios

– Incidence

• 13-34% in ICU

• 22% in cardiac surgery

• 3-54% in stroke

Current Trials

• The CHEST Trial

– Crystalloid Versus Hydroxyethyl Starch Trial

– 7000 ANZ ICU patients

– HES 130/0.4 versus saline

– 90 day mortality; need for RRT (secondary end-point)

• The Scandinavian Starch for Severe Sepsis/Septic Shock Trial

– 800 ICU patients

– HES 130/0.4 or Ringer’s acetate

– Mortality or dialysis dependence at 90 days after infusion

Time to put it all together

Summary

• When should fluid be given:

– Fluid should be given in a time-sensitive manner

• How much fluid to give

– Directed toward the goal of improved stroke volume as evidenced by return of

HR to normal, CRT <2 second, peripheral pulses and BP as well as correction of

Hb and ScvO2>70%

• Crystalloid or albumin?

– Probably doesn’t matter

– No place for HES, gelatins or dextrans in paediatric septic shock